Acute Retropharyngeal abscess

in adult
Inderdeep Singh*, Vikas Gupta, Sunil Goyal, Manoj Kumar, Lakshmi Ranjit, Salil
Gupta

Oleh : Willie Hardyson (01073170144)

Pembimbing : dr. Christian Harry S., Sp. THT-KL

Retropharhyeal abscess definition

A collection of pus in
the tissues in the
back of the throat

2
Introduction
Acute retropharyngeal
abscesses are generally
described as a disease in
children

Uncommon in adult but

potentially lethal infection
involving deep neck spaces

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Introduction
Secondary to trauma,
foreign bodies, or as a
complication of dental
infection

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EPIDEMIOLOGY
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• Typically occurs in children less than 6 years old
but can occur at any of age

• Half of retropharyngeal abscesses started from

upper respiratory tract infectionretropharingeal
suppurative lymphadenitis abscess formation

• One-fourth of retropharyngeal abscesses from

trauma leading to infection in retropharingeal
space abscess formation 6
ANATOMY
7
Patophysiology
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 Retrophageal space infection

Suppurative adenitis of retropharyngeal lymph nodes

Leads to phlegmon and abscess formation

(Group A Streptococcus, Streptococcus pyrogens, Staphylococcus aureus, Fusobacterium,
Haemophilus species, and other respiratory anaerobic organisms)
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Retroph Gradual
aringeal upper Asphyxiat SEPSIS
abscess airway ion if left can DEATH
grows in obstructi untreated occur
size on

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Case 1
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• 46 years old male
• Come with complaints of sore throat of 10 days
duration
• progressive dysphagia and odynophagia of 6 days
duration
• Progressive neck swelling for last 5 days
• No history of difficulty in breathing or noisy
breathing, dyspnea, trismus, previous trauma/
foreign body ingestion or dental problems

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Examination:

• Afebrile and normal vital paramater

• Diffuse neck swelling in both sides of neck and
extending superiorly from level of mandible to
inferiorly up to clavicle.
• Posteriorly it extended up to trapezius which was
more on left side then right side

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• Ultrasound of neck done 2 days prior: showed
subcutaneus edema and features suggestive of cellulitis

• The patient was started on oral antibiotics

• An urgent CECT (contrast enchanced computed

tomography) of neck and chest  revealed an ill-defined
necrotic peripherally enhancing collection epicentered in
the retropharyngeal space extending to prevertebral and
danger spaces posteriorly, laterally to bilateral para-
pharyngeal spaces with involvement of carotid space and
displacement internal jugular vein laterally
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• There was also involvement of the anterior visceral on the
left side and thrombosis of the left internal jugular vein.

• Inferiorly it extended into the posterior mediastinum with

indentation of the left atrium and anterior displacement of
the cardiac structures

15
• Axial cuts of suprahyoid and infrahyoid region
showing collection in the retropharyngeal and
retrovisceral spaces respectively 16
• C: Axial cut showing collection in the posterior
mediastinum with indentation on the left atrium
• D: Sagittal cut showing the collection in danger space
extending from the skull base up to the diaphragm with
involvement of the posterior mediastinum 17
• Patient started injectable broad spectrum antibiotics

• Planned to do an urgent incision and drainage through the

cervical (in nassal intubation for general anesthesia)

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• A : Showing the planning of the cervical incision
• B : Elevation of skin flaps
• C : Opening of the anterior visceral space with pus pockets
(dark green colour pus)
• D: Showing pus in right parapharyngeal space with lateral
displacement of internal jugular vein (White arrow) 19
• E : Green arrow pointing towards thrombosed left internal
jugular vein
• F : Blue arrow pointing towards retropharyngeal space
• G : Showing 2 drains in situ secured with temporary
tracheostomy through a separate incision.
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• Pus sent for culture E-coli

• Antibiotics were changed based on sensitivity report

• Patient was decannulated after 2 weeks and at the same

time the drain was also removed

• The staples were removed the next day following which

the patient was discharged

• He was kept on follow up till the closure of the

tracheostoma.
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• Showing the surgical site with drain in situ on left side and
healing tracheostoma. The neck swelling has completely
resolved.
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Case 2
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• 72 years old female was reffered to hospital (with
endotracheal tube intubation)
• Complaints of progressive odynophagia, dysphagia
and diffuse neck swelling since 5 days
• Trismus for the past 2 days.
• There was no history of noisy breathing or
dyspnoea.
• She gave history of a fish bone ingestion 5 days
back prior to onset of the symptoms.

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Examination:
• Afebrile with normal vital parameters
• Diffuse right sided neck swelling from hyoid to
clavicle
• Oral cavity and oropharynx revealed trismus with
mouth opening limited to 2cm
• Hopkins rod examination revealed a reduced glottis
chink due to edema of aretenoids and epiglottis.

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Urgent CECT neck and chest:
• Heterogeneously enhancing collection extending
from skull base to the level of C6 vertebral body
involving the retropharyngeal space
• Extending into the right parapharyngeal space and
tracking along the carotid sheath and right lobe of
thyroid medially

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• Showing collection of pus in retropharyngeal space and
right parapharyngeal spaces
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• Patient was started on broad spectrum injectable
antibiotics
• An urgent incision and drainage of the abscess
was done through the cervical approach under
general anaesthesia.
• Tracheostomy was performed for securing the
airway.
• Dark yellowish pus was drained from the
retropharyngeal, right parapharyngeal and carotid
spaces.
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• Aggressive broad spectrum antibiotics were
continued
• Culture report did not show any growth
• Drain was removed after 7 days postoperatively
• Patient was decannulated and discharged on 14th
day postoperative

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Case 3
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• 74 year old male
• Complaints of progressive odynophagia, dysphagia
and progressive neck swelling for 5 days
• Restricted mouth opening for 2 days.
• No history of dyspnea or respiratory distress.
• No history of dental problems or trauma or foreign
body ingestion.

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Examination:
• Patient was afebrile with normal vital parameters.
• Examination revealed swelling in midline of neck
extending from the mandible to the clavicle
• Examination of oral cavity and oropharynx revealed
trismus with mouth opening limited to 1 cm.
• Rigid Hopkins examination could not be performed
because of the severe trismus

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• Showing midline neck swelling in a patient with
retropharyngeal abscess
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• CT scan revealed heterogeneously enhancing
collection involving the retropharyngeal space
extending from skull base to superior mediastinum.
• There was evidence of collection in the left
parapharyngeal space, muscular space and anterior
visceral space.

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• B: Axial CT scan showing involvement of retropharyngeal
space in suprahyoid neck.
• C: Axial CT scan showing involvement of retrovisceral
space, left parapharyngeal space, muscular space and
anterior visceral space in infrahyoid neck. 35
• Patient was started on broad spectrum injectable
antibiotics
• An urgent incision and drainage of the abscess was
done with tracheostomy under general
anaesthesia.
• Intraoperatively pus was drained from the
retropharyngeal, left parapharyngeal spaces,
muscular space and anterior visceral space

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• Pus culture was positive was Staphlococcus aureus
• Antibiotics was changed to culture directed
sensitivity report.
• Drain was removed after 7 days post operatively.
• Patient was decannulated and discharged on 14th
postoperative day

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Discussion
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• The retropharyngeal space is a potential space
between buccopharyngeal fascia covering the
posterior pharynx, esophagus and the alar fascia
• It extends from the base of the skull into the
superior mediastinum.

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• Acute retropharyngeal abscess is
usually unilateral
• Primarily seen early in childhood
because these lymph nodes tend
to regress with age
• Upper respiratory infections
cause most retropharyngeal
disease in children because
these lymph nodes receive
drainage from the nose, sinuses,
and pharynx.
• Trauma to the posterior pharynx ,
secondary infection and foreign
body will cause abscess both
adult or children.
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de Clercq LD et al in its paper on retropharyngeal abscess in
adults have stated that patients usually present with:
• fever
• odynophagia
• dysphagia
• dyspnoea
• drooling
• cervical rigidity (torticollis)
• 'hot potato' or hyponasal voice,
• sepsis

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• On inspection: might see a bulging of the pharyngeal wall.
• The mucosa may be swollen and inflamed
• Causative organism: both aerobes and anaerobes
• In this case series the organism are: E-coli, and
Staphloccoccus aureus
• Culture report, guides the choice of antibiotics.

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• CECT is the radiological investigation of choice to confirm
the diagnosis and evaluate for spread of infection into
adjacent deep neck spaces
• Plain radiography, USG, and MRI can be use too
• USG usefull because: easy, bedside procedure, guided
aspiration of pus, and no radiation.

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Complications:
• Airway compromise taken to operating room for securing
the airway (nasotracheal intubation/ tracheostomy)
• Abscess rupture aspiration pneumonia
• Surgical intervention will be done if there are more
complicated or severe cases

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Surgical indication:
• airway compromise
• critical condition
• septicemia
• complications,
• descending infection
• diabetes mellitus
• no clinical improvement within 48 hours of the initiation of
parenteral antibiotics.

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• Abscesses >3 cm in diameter that involve the prevertebral,
anterior visceral, or carotid spaces, or involve more than two
spaces, should be surgically drained.
• Superficial abscesses  simple intraoral or extraoral incision
• Deeper and more complicated infections more extensive
external cervical approach for drainage
• Large and multilocular abscesses  incision and drainage

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• Lemierre syndrome: suppurative thrombophlebitis of the
internal jugular vein, as a result of extension of infection into
carotid space
• Pathognomonic findings  swelling and tenderness at the
jaw angle and along the sternocleidomastoid muscle, with
signs of sepsis (spiking fevers, chills) and evidence of
pulmonary emboli
• Downward infection will cause mediastinitis  transthoracic
drainage is needed.

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Conclusion
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• The aim of discussion  to highlight the mode of
presentation of a retropharyngeal abscess
• Successful outcomes depend on early
identification and urgent aggressive management
• Highlight treatmentsecure the airway surgical
drainage and antibiotics (based on culture)

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